By Dr. Ann Croghan, PT, DPT, CLC, and CAPP-OB trained with introduction by Stephanie Prendergast, MPT
A few months ago I shared a link to an article I was interviewed for in Men’s Health Magazine about postpartum sex on our PHRC Facebook Page. I was disappointed there was not better coverage about postpartum pelvic floor physical therapy in this article since that was the bulk of my interview. Postpartum care in the US leaves a lot to be desired and my post mentioned this. Pelvic floor physical therapist Ann Croghan chimed in, commenting on an antenatal and postpartum program that sounds too good to be true:
Since Ann and I connected back in April, the American College of Obstetrics and Gynecology release a position paper regarding a “4th Trimester” and regarding the need for improved postpartum care. Pelvic floor physical therapy only received a brief mention but I suppose we should be grateful it was mentioned at all. Ann and Sarah Hudelson have created a program that should be in every hospital in the United States and available to all postpartum women. The ACOG Guidelines are a start to improve postpartum care, pelvic floor physical therapists need to continue to advocate for ourselves and the work we do. I suspect Ann and Sarah’s story will inspire you the way it did me, check it out.
Inspiration behind program: The inspiration for this program came out of a really poor birthing experience that I had with my first child when I lived in Denver. I was already practicing as a pelvic PT and I had completed one class for CAPP-OB certification through the SoWH. When I took the Fundamentals in Pregnancy and Postpartum class, I was thinking why don’t we have PTs on the L&D floor? This question continued with me as I moved my way through an uncomplicated pregnancy. When I was 34 weeks GA, the midwife group I was working with informed me that my baby was in a breech presentation. They referred me to an acupuncturist, a chiropractor, pool, and a lot of inversions. I was grateful for the interventions by the chiropractor, but I was confused as to why a PT wasn’t included. I ended up doing everything recommended as well as including a PT co-worker for some of the “pelvic balancing” that the chiropractor was doing. Ultimately, my baby never turned and I refused to consent to cesarean until I had labored for >12 hours and decided that I had no other option.
I was shocked at the lack of support that I had in the antenatal period, but even worse was the amount of pain and lack of support in the postpartum period. My recovery from my cesarean birth was a long process. My external obliques were torn during the surgery, so it hurt to have my baby on my stomach to nurse. Her little feet would hit my incision and pain would almost make me pass out. Pain and a drop in my blood pressure prevented me from getting out of bed by myself and the only help I had was from my husband. A nurse even commented to me “Wow, you really are taking your time” when I was trying to engage my TrA and log roll to sit up in bed. The next few days were filled with pain, tears, asking for help and not receiving. “Why can’t PT come help me” was a question I asked the nursing staff and physicians. They all said, “PT doesn’t work on this floor”. And why not was all I could think. Why not?
When I made it home, five days later, I was still in significant pain with mobility, with gas, with urination, with bowel movements. Luckily, I am a pelvic PT and knew right away that NONE of this was normal. I went and saw of few of my pelvic PT friends and felt 50% better in a few weeks. It would take me 18 more months to feel 90% better with the help of my own knowledge and with the help of my PT friends.
Two months into my maternity leave and postpartum recovery, I decided that this system needed to change. So I moved to Salida, CO in order to work for a small hospital where I knew the community would be supportive of a change. That leads me now: four years postpartum from my cesarean birth and 18 months postpartum from my VBAC baby. I have worked to establish a mom supported culture at HRRMC and in the home birth community. My program is supported by physicians, nurses, midwives, and moms because we all know that this is what’s best for moms and for families.
What is the program: The physical therapy department had an existing pelvic physical therapy program started in 2008 by Sarah Hudelson, PT, DPT. I started the physical therapy obstetric program October of 2014 after the poor birthing experience. The program started with inpatient visits to all women who had a cesarean birth and quickly progressed to all births! We then added on a standard 6 week postpartum visit and, more recently, a standard 3rd trimester visit. We will see any woman who is having dysfunction, but the standard visits were designed to attempt to improve patient outcomes.
The 3rd trimester visit is newer, started in 2016, and is slowly growing. I had another baby in September of 2016, so we have recently picked our efforts back up in 2017. Since we have a small tight knit community, our mothers have been good about spreading the word on this program. One month ago we were able to get this 3rd trimester visit standardized with one of the two physician practices where they have a referral paper in the mother’s 3rd trimester packet. We, the physicians and PTs, are hoping that this helps remind them to refer. This visit(s) includes: what happens in normal birth from an orthopedic/PT perspective, pelvic balancing, uterine balancing (after 36 weeks GA), and a labor and positioning visit where moms can bring a birth partner. We then write up a letter with our recommendations for labor and birth, send one with the client, one to the nursing staff at the hospital, and one to the physician. Our goal is to avoid orthopedic injury, decrease perineal tear rate, decrease primary cesarean rate, educate mothers on pain relieving techniques/positions in order to avoid epidural use, and improve maternal mental health. We are tracking our outcomes for orthopedic injury, tear rate, primary cesarean, and epidural use. Hopefully we will be able to present some of these statistics at CSM in 2019 or 2020.
The inpatient visit is structured around basic biomechanics, isometric activation of TrA and pelvic muscles, prolapse prevention with bowel mechanics and discussions around lifting baby, addressing any surgery or tearing she may have had, a list of common but not normal symptoms she may experience that she should get help with if they come up, and she is assessed for a DrA. All the moms are fitted with a binder, which we know is controversial, but we felt like it was the best option for our inpatient PTs in order to help them make decisions on care.
The 6 week follow-up visit is mostly standardized, with the majority of physicians remembering the referral. In this visit, we do a basic pelvic muscle assessment and intake and make our recommendations from there. One piece that has been interesting about this 6 week visit is the amount of mothers that present with some issue with breastfeeding. In our small town, there are not many places to refer out. I found myself not able to fully help them meet their breastfeeding goals and I was making positional recommendation based on their dysfunction (prolapse, tear recovery, cesarean scar pain, coccydynia, etc) and these suggestions were not always protective of their breastfeeding relationship. With the help of the Chaffee County Breastfeeding Coalition, I became a Certified Lactation Counselor and opened my own lactation company to see clients privately for lactation support. I can also answer questions during my PT session related to breastfeeding and positioning. I found that pelvic PTs, and PTs in general, can be perfect providers for lactation support. But that is another topic for another time!
How you got it going: I started with speaking with the labor and delivery nurse manager about PT care of the post-surgical patients and discussing the role that PT has in caring for moms post-surgical (ie: post cesarean). The nurse manager and I discussed the role PT has with all orthopedic surgeries and how these surgeries were no different: they required mobility, isometrics, swelling, and pain management. We then went to the OB services meeting and discussed PT seeing all cesarean birth moms day one post op with the physician staff. We decided to make PT a standard visit. This was key in the success of our program. With PT being standard, the physicians don’t have to write an extra order. The box is already checked on physician visit note. I feel like programs that give the physicians or the nursing staff a checklist of when to use PT will fail because the PTs should be the ones deciding if a person should be seen or not seen, not other medical professionals. I then tried the inpatient PTs on the basics on our program including basic evaluation of DrA. We then also trained the nursing staff on the role of the PTs on the labor and delivery floor so they would know what to expect of us. The physicians, nurses, and moms loved the visits from PT so much that in two months all births had a standard PT visit. From there, we attended all OB service meetings to normalize our role on the labor and delivery floor. After a year we introduced our 6 week postpartum follow up. In 2016/2017 we then introduced our 3rd trimester visit utilizing the “Save the Perineum” campaign and a goal to reduce the primary cesarean rate. We are still working on growing the 6 week and 3rd trimester visit and we still attend the OB service meetings. I’m very active on our social media as well as offering a free postpartum recovery classes in order to continue to grow our community interest and community referrals. This program is a labor of love and is not without hard work and significant effort.
Our care providers, both physicians and nurses, are amazing. They have trusted this process and have been supportive of my dream. I am so thankful for their support and advocacy.
What’s next: At this point our biggest task is to continue to increase participation in the 3rd trimester visit and the 6 week visit. Our physicians are working on trying to find a way to prompt those visits, and I think we are almost there! My 3-5 year goal is to have PT be more involved during birth. There are a few physicians that will text or call me and ask me questions about mother positioning if labor is not progressing. What I want is the ability/availability for PT to be a part of the birthing team during the labor and delivery. My 5-8 year goal is lift our VBAC ban and improve maternal care from this standpoint. I see myself as a birth advocate, and I want for the women in our community to know they have a choice in how they birth. We are improving this by empowering women to make choices in their own position during labor and delivery; this will soon be followed by being able to make the choice to VBAC or have a secondary cesarean birth. Another goal that I have involves our lactation support and how PT is utilized for lactation support, but, again, that is a topic for another time!
Our goal is to present our program in four different poster presentations for CSM 2019 in D.C. We then hope to present the entire program with all of the data at CSM 2020 in Denver. Hopefully we are accepted!
Feedback: Here are some notes from our supporters!
“From helping relieve back and pelvic pain during pregnancy to helping women feel normal again after delivery, pelvic PT has been very beneficial for my OB patients. Pain, incontinence, and dyspareunia seem to be symptoms women think are normal after having children – until they go see a pelvic specialist and find out they can get better. Patients often realize that these taboo topics are very common among other women and feel empowered to improve their symptoms and talk with other women about what should be considered normal during pregnancy and after having children.” – Dr. Vanna Irving MD with practice specialty in OB/Gyn
“Our perinatal physical therapy program is unlike anything I have ever had the pleasure to work with, even at much bigger urban hospitals. The service that Ann and Sarah provide empowers women to approach childbirth with confidence having created a personalized plan for both labor and delivery. Not only does it give them practical tools to both relieve pain and prevent injury, but it also follows them after birth to ensure their recovery is without chronic problems like incontinence and pelvic pain. I refer all my pregnant patients to them.” – Dr. Daniel Lombardo MD with practice specialty in OB/Gyn
“The HRRMC pelvic floor physical therapists have not only given our moms the tools to recover well postpartum, but have equipped our nurses with safe, productive labor and pushing positions for our laboring moms. I am relieved to know that we are doing everything we can to prevent long-term problems that can result from pregnancy and childbirth. Our pelvic floor PT program is a success and a great service to our childbearing population in Salida.” – Tracey Hill, RN, BSN, MS
“The OB PT program was absolutely essential for my second pregnancy as well as my postpartum recovery with both of my babies. I suffered third degree tears with both of my babies and I believe I wouldn’t have the recovery and healing that I had without pelvic PT. The care I received from Ann was above and beyond what one would expect of a medical professional and I am forever grateful to have been referred to her initially. It is so evident that she is genuinely concerned with the well being and full recovery of her patients. She has a true gift. My hope is that pelvic PT becomes more widely used as a norm as I feel every single woman could benefit from it postpartum.” – Local Salida Mom
Congratulations to Ann and Sarah for their work and program! They are bringing pelvic floor physical therapy to it’s well-deserved place and helping tons of women. We thank Ann for sharing her story and ideas on how to create similar programs in our own geographical areas!
Women can find pelvic floor physical therapists through the American Physical Therapy Association’s PT Locator.
Additional Reading and Podcasts: